Thursday, April 30, 2015

I just returned from the EduAction conference in Israel, where I got to talk to the Jerusalem mayor, Nir Barkat about school choice, and to hear about the school choice program he implemented when he became mayor.

Volunteer Pilots Fly Shelter Dogs to New Homes to Save Them From Euthanasia
"One of the biggest issues for animal shelters nation-wide is that some regions are overflowing with adoptable dogs while others never have enough. Wings Of Rescue, an extraordinary volunteer organization run by dedicated pilots, flies dogs from shelters overflowing with animals to those that can find them new homes. Often, the dogs they transport would have been euthanized hours later if it weren’t for these pilots.
The organization has saved over 12,000 dogs since 2009, when it was formed. Flights cost roughly $80 per dog, and you can donate to their cause on their website."

Rescue Waggin’
"Location is everything: Some cities have too many homeless dogs and puppies; others have waiting adopters.

"So every day, the PetSmart Charities® Rescue Waggin’ program picks up selected dogs and puppies from partner shelters in areas where there are more dogs and puppies than can be placed through adoption. Then we transport them to places where they get adopted, often within days.

"In fact, the Rescue Waggin' program has helped save the lives of more than 70,000 dogs and puppies since we started it in 2004."

"Two major obstacles have prevented us from helping W.B. The first concerns his desire to donate a kidney while he is still alive. In his weakened state, will he tolerate the anesthesia and surgery? Or will they hasten his death? If he survives the surgery, will he ever leave the hospital?

"As doctors, we have sworn to do no harm. And yet, every Wednesday and Thursday morning, we remove kidneys from living donors. These patients are not getting any medical benefit from donating one of their kidneys—to the contrary, they are accepting a small risk of complications, including hypertension and a slightly increased likelihood that their remaining kidney will fail. But they do experience a very real, if intangible, benefit: the experience of saving someone’s life.

"In evaluating W.B.’s request, we had to weigh carefully not only the risk to him—which W.B. clearly understood—but also the risk that a donor death after surgery would pose to our hospital. Transplant-surgery programs in the United States are scrutinized by an alphabet soup of federal and nongovernmental entities. Centers with worse-than-expected transplant outcomes can be placed on probation or shut down. A single bad outcome involving a living donor can lead to an investigation. While there are good reasons for this monitoring, it can cause surgeons to avoid complicated cases and innovation. If we were to remove one of W.B.’s kidneys, and he died one, two, or even six months after surgery, his death would be a very public black mark on our program.
...
"From the earliest days of transplantation, surgeons subscribed to an informal ethical norm known as the “dead-donor rule,” holding that organ procurement should not cause a donor’s death. In practice, this meant waiting until patients were by all measures completely dead—no heartbeat, no blood pressure, no respiration—to remove any vital organs. Unfortunately, few organs were still transplantable by this point, and those that were transplanted tended to have poor outcomes by today’s standards.

As the field burgeoned, doctors could see the potential to save ever more lives—if only more organs could be found. In 1968, in an effort to address the shortage of transplantable organs (as well as the delivery of futile care to people in irreversible comas), an ad hoc committee at Harvard Medical School suggested that patients with no identifiable brain function could be designated as “brain-dead,” thereby making them candidates for organ donation. The definition the committee came up with informed the Uniform Determination of Death Act, a model state law drafted in 1980 and subsequently enacted by most states, which holds that brain-dead patients are legally dead. Under the new state laws, doctors could remove organs from patients whose hearts were still beating without violating the dead-donor rule.

Although the dead-donor rule is ostensibly a fine standard, it doesn’t address the situation of most people who are terminally ill. Nor do the laws regarding brain death. Today, terminally ill patients’ best—in many cases, only—chance of passing on their organs is via a wrenching process known as donation after circulatory death, or DCD, whereby a patient’s doctor withdraws all life support while an organ-recovery team stands by. For organs to be successfully transplanted this way, however, the donor typically needs to die within an hour or two of being taken off life support—otherwise, decreased blood flow leaves the organs unsuitable for transplantation. Even when DCD organ donors do die in the allotted time, we tend to recover fewer organs from them than from brain-dead donors, whose bodies aren’t subjected to this drawn-out process.

Over the course of a single week while we were writing this article, three potential DCD donors at our transplant center had life support removed with the intention of donating their vital organs, but failed to die quickly enough.
...
"When the term brain death was introduced half a century ago, it was meant to provide an objective legal definition for a group of patients whom we might otherwise describe as “unrecoverable.” Of course, we also recognize as “unrecoverable” many patients who do not meet the standard for brain death. Those who have suffered devastating strokes or heart attacks, or who have sustained major head trauma, may not be brain-dead even though they have brain injuries that render them unable to survive without life support.

"A more useful ethical standard could involve the idea of “imminent death.” Once a person with a terminal disease reaches a point when only extraordinary measures will delay death; when use (or continued use) of these measures is incompatible with what he considers a reasonable quality of life; and when he therefore decides to stop aggressive care, knowing that this will, in relatively short order, mean the end of his life, we might say that death is “imminent.” If medical guidelines could be revised to let people facing imminent death donate vital organs under general anesthesia, we could provide patients and families a middle ground—a way of avoiding futile medical care, while also honoring life by preventing the deaths of other critically ill people. Moreover, healthy people could incorporate this imminent-death standard into advance directives for their end-of-life care. They could determine the conditions under which they would want care withdrawn, and whether they were willing to have it withdrawn in an operating room, under anesthesia, with subsequent removal of their organs."
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I will participate late in the day, in a conversation with the mayor of Jerusalem, followed by the President.

19:00: Nobel laureate in economics for 2012, Professor Alvin Roth , a conversation with the Mayor of Jerusalem, Nir Barkat , education and implementation of economic theories in the public sector.

19:30: Address by President Reuven (Ruby) Rivlin
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I gather that this last session may be carried on Channel 2, although I expect that my conversation with the mayor will be conducted in English. (I also expect that it will focus on school choice.)
*****
Update: here's the coverage from the Jerusalem PostDovrat worries Education portfolio has become a booby prize

Monday, April 27, 2015

"The current system is a qualified failure. For the past decade, transplant operations for all organs have hovered between 27,000 and 29,000 annually, and, in 2014, was the lowest it's been in 11 years.The European model of "presumed consent," wherein a person's organs are taken posthumously unless an individual has specifically forbidden their retrieval, is not a potent solution as less than one percent of deceased individuals are medically eligible to donate."Hence, there is a desperate organ shortage in the United States. The situation in other countries, especially poorer countries without good access to dialysis — a death sentence without immediate transplant — is even worse. As a result, the overseas black market is burgeoning. The World Health Organization estimates that 10 percent of all transplants are performed under shadowy, illicit conditions where the risks are high: Corrupt brokers deceive impoverished and illiterate donors about the nature of surgery, cheat them out of payment, and ignore their post-surgical needs. For the recipient, organ quality can be poor and post-operative management dicey. (The exception appears to be Iran, where organ sales are monitored by the government. There, potential donors exceed the number of needy patients.)..."Compensating organ donors is not a new idea. In 1983,Al Gore, who championed NOTA, explicitly suggested rewarding donors if altruistic volunteering did not keep up with demand. Moreover, NOTA'slegislativehistory implies that the law's felony provision against "valuable consideration" in exchange for an organ was intended to prohibit brokered or direct cash sales between buyer and seller. It is silent regarding a system of in-kind, third-party compensation.

Here is a plan for donor benefits: A governmental entity, or a designated charity, would offer in-kind rewards, like a contribution to the donor's retirement fund, an income tax credit, or a tuition voucher worth roughly $50,000 in value. (This is the amount typically proposed by advocates of incentives.) To enhance deceased donation, a funeral benefit could be offered.

With a third party providing the reward, all recipients, not just the financially secure, will benefit. An imposed waiting period of at least six months would help limit impulsive live donation and, most important, any subsequent remorse. Prospective donors would be carefully screened for physical and emotional health, as is done for all donors currently. Their kidneys could be distributed, according to exiting allocation policies now in place for cadaver organs.

Donors would be guaranteed follow-up medical care for any complications, which is not ensured now. And the cost of the benefits could be underwritten by the enormous savings from dialysis.

Will rewarded donation attract only low-income prospective donors? Perhaps. One option is to require a minimum income for donors, but that strategy prevents all interested parties from participating. Better to start with the assumption that low-income people are capable of making decisions in their own interest. In the end, regardless of who ends up donating, a sound plan ensuring that donors are thoroughly informed, their health protected, and their sacrifice amply rewarded is an ethical one.

How to achieve this? We should start with pilot projects. The Department of Health and Human Services probably could initiate pilot trials, if motivated. The Center for Medicare and Medicaid Innovation has impressively broad authority. In theory, the Center could issue NOTA waivers to academic medical centers interested in administering a pilot program wherein living donors would be rewarded with five years of Medicare coverage.

States should also get involved. The late Pennsylvania Governor Robert P. Casey, who had received a heart and liver transplant a year earlier, signed a 1994 law that would enable a bereaved family of an organ donor to get a burial benefit of up to $3,000 paid by the state directly to the funeral home. State health officials ended up with cold feet, fearing that the law flouted NOTA, but some bold state should proceed with a funeral benefit and force the Department of Justice to action, spurring a vital national debate in the process.

Congressional action is another approach. Lawmakers could amend NOTA to permit pilot trials of incentives by clarifying the intent of the law as a restraint on cash exchange between buyer and seller with or without a broker. The need for a new approach to expanding the supply of donors should resonate with lawmakers on several levels. The first is public health (needless deaths), the second is fiscal (the enormous cost to Medicare — roughly seven percent of its budget is spent on dialysis and its complications), the third is human rights (the global black market); and the fourth is race (minorities are disproportionately disadvantaged by the organ shortage as they are less likely to be referred for transplant)."

It begins this way:
"Love isn’t the only thing money can’t buy—blood is, too. And yet, though no money is exchanged, blood can find ways of getting to the people who need it, though not often in ways where demand and supply are aligned. In the days following the Boston Marathon bombing, people rushed to give blood in support of the victims, eager to donate one of the human body’s most precious resources to others, free of charge.

"While this altruistic impulse is certainly commendable, according to Carmen Wang, it is sometimes misguided. “In that instance, the American Red Cross had to issue an announcement thanking would-be donors and informing them that they already had an adequate supply of blood.” But at other times, for example when the flu or cold virus afflicts many regular donors, blood supply dips, and blood banks have trouble finding people willing to give."

Friday, April 24, 2015

Frank Bruni had a recent NY Times column that reminded me of the chain of high school suicides:
"Between May 2009 and January 2010, five Palo Alto teenagers ended their lives by stepping in front of trains. And since October of last year, another three Palo Alto teenagers have killed themselves that way, prompting longer hours by more sentries along the tracks. The Palo Alto Weekly refers to the deaths as a “suicide contagion.”

Sometimes something similar happens with good acts, and I was reminded of that by this recent story from Israel (about a different kind of chain of kidney donations than I usually write about):

Chain Reaction of Good Will
"Avraham Shapira donated a kidney to a stranger and set off a series of altruistic gestures. A few months later his cousin, Yehuda Rabinovich, was inspired by Shapira and also donated a kidney to a stranger. From there the movement spread around the Shomron region. So far six people have donated kidneys to complete strangers."

Thursday, April 23, 2015

Here's an early announcement of a conference scheduled for February 2016, organized by the American Society of Transplantation, which reflects some of the intense discussion going on in the transplant community about how to alleviate the shortage of transplantable organs.

Wednesday, April 22, 2015

The National Kidney Registry has completed a new, long non-simultaneous nondirected donor chain, maybe the longest to date. Here are some stories, from the local press at some of the hospitals involved.

Kidney exchange in which Allegheny General Hospital participates enables 34 transplants
"A Somerset County man and 33 other renal disease patients received new kidneys this year in an unprecedented national chain of organ transplants, Allegheny General Hospital announced Wednesday.
The North Side hospital is among 26 domestic transplant centers that participated in the exchange, run through March by the nonprofit National Kidney Registry. It is the largest multi-center paired kidney exchange so far in the United States, the registry said."

"A Wisconsin woman received the final kidney transplant at the University of Wisconsin Hospital in March, completing the longest chain of kidney donations.

"UW Hospital is a member of the National Kidney Registry, an organization that works to match kidney donors with recipients for transplants. The registry organized the completed kidney chain, which started and ended at UW Hospital.
...
"Of the 68 people in the kidney chain, 34 donors and 34 recipients, five were connected through UW Hospital, Miller said."

D.C., Md., Va. hospitals participate in largest-ever multi-hospital kidney transplant chain
"With 34 donors and 34 recipients, Chain 357, nicknamed a “chain of love,” is the country's largest-ever multi-hospital kidney transplant chain. The National Kidney Registry worked with 26 hospitals across the country to make sure every link of the chain connected.
"Since Jan. 6, the chain has bounced across the country, including stops at MedStar Georgetown Transplant Institute in Washington, D.C.; Walter Reed National Military Medical Center in Bethesda, Md.; University of Virginia Hospital in Charlottesville, Va.; and two bouts at the University of Maryland Medical Center in Baltimore, Md."

"Although 90% of Renewal’s donors are ultra-Orthodox, about half their recipients are people like Sarna, who come from the broader Jewish community.

"The average wait time for a kidney through Renewal is six to nine months.

"Because many ultra-Orthodox rabbis believe that organ donation from dead bodies is against Jewish law, Renewal focuses solely on live donors. That puts Renewal’s donors in an extremely rare group of several hundred Americans who, each year, donate their kidney altruistically to a stranger.
...
"Researchers are studying Renewal’s model to see whether it can be replicated in other race- and faith-based communities. Meanwhile, one African-American transplant surgeon is setting up a group modeled on Renewal in a prominent Harlem church.

"Anthony Watkins, an assistant professor of surgery at Weill Cornell Medical College, has witnessed Renewal’s work firsthand, ever since he began his transplant fellowship six years ago. “I’ve always thought that what Renewal does is spectacular and fantastic and [that] maybe this could be duplicated in other communities,” he said.

"Watkins thinks that by using Renewal’s model — appealing to African Americans to help fellow African Americans — he can persuade people to donate in greater numbers. “I think once you establish a good rapport and knowledge and education… you can get altruistic donors to step forward,” Watkins said. But how many people are willing to donate a live organ to a stranger?
...
"Renewal facilitates an average of about 50 kidney transplants a year. About three-quarters of those transplants are ultra-Orthodox donors giving to a Jewish stranger.

"Ultra-Orthodox Jews account for just 0.2% of America’s population. Yet last year, by the Forward’s estimates, they accounted for up to 17% of the people who donated a kidney to strangers.

"Rees realized that if Renewal’s model of communally focused organ donation could be extrapolated to the general population, it could create tens of thousands of additional kidney donors. The waiting list could be reduced to zero. “That’s what Renewal has achieved,” Rees said, “and that is nothing short of amazing.”

"Rees contacted Duke University to see if researchers there could investigate whether Renewal’s model could be replicated in Christian communities.

"Last year, two Duke professors, David Toole and Kim Krawiec, put together an interdisciplinary team of faculty and students, including lawyers, physicians, sociologists and theologians, to examine new methods of increasing living kidney donation.
...
"Renewal leads donors and recipients through every stage of the transplant process. It is particularly important for kidney donors, who receive very little financial support from insurance companies and the state. Renewal covers lost wages, transportation and any necessary hotel costs. It also offers domestic support such as house cleaning, laundry services and catering. Reiner said that the average cost of a transplant, including the group’s administrative overhead, is about $20,000.
...
"The United Network for Organ Sharing, which tracks donations nationally, counts a kidney donation as “altruistic” only if the donor does not specify to whom the kidney is given. Last year it tracked 180 such altruistic donations.

"Because Renewal’s donors choose the recipient of their kidney — even though they have no personal relationship with them — UNOS categorizes them in a larger pool of 1,273 living donors who directed their kidney to a “non-relative.”

"Based on this method, Renewal’s donors account for about 2% or 3% of living donations to non-family members.

"But Duke University’s Toole says that it is unfair to compare Renewal’s donors to most other donors in this larger pool because most of those donors know the recipient of their kidney. Renewal’s donors give to strangers. “What makes the model so interesting,” Toole said, is that “it’s some in-between space” between directed donations and altruistic donations."
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Dynamic Games

In many economic, social, and political settings, participants interact strategically not just once but over time.

When raising its import tariffs today, for example, a country will try to anticipate the reactions of its trading partners tomorrow. And an oligopolistic firm can learn from its rivals’ past pricing behavior so as to gauge what prices they are likely to set now.

The Summer School will emphasize theoretical aspects of dynamic games, but will also include work on experiments.

He writes:
"This column will present the game-theoretic results contained in the original Gale-Shapley paper along with Roth's subsequent analysis. Pathak calls the deferred acceptance algorithm "one of the great ideas in economics," and Roth and Shapley were awarded the 2012 Nobel Prize in economics for this work...

He gives a straightforward mathematical treatment of some of the main theoretical results, in context:

"Using ideas described in this column, economists Atila Abdulkadiroglu, Parag Pathak, and Alvin Roth designed a clearinghouse for matching students with high schools, which was first implemented in 2004. This new computerized algorithm places all but about 3000 students each year and results in more students receiving offers from their first-choice schools. As a result, students now submit lists that reflect their true preferences, which provides school officials with public input into the determination of which schools to close or reform. For their part, schools have found that there is no longer an advantage to underrepresenting their capacity.

The key to this new algorithm is the notion of stability, first introduced in a 1962 paper by Gale and Shapley. We say that a matching of students to schools is stable if there is not a student and a school who would prefer to be matched with each other more than their current matches. Gale and Shapley introduced an algorithm, sometimes called deferred acceptance, which is guaranteed to produced a stable matching. Later, Roth showed that when the deferred acceptance algorithm is applied, a student can not gain admittance into a more preferred school by strategically misrepresenting his or her preferences."

- See more at: http://www.ams.org/samplings/feature-column/fc-2015-03#sthash.LoiUEphE.dpuf

Saturday, April 18, 2015

Here's a paper reviewing kidney exchange around the world, from an Australian perspective (Paolo Ferrari has been one of the Australian pioneers), and advocating for a national kidney exchange program in Switzerland...

a Service of Nephrology. Geneva University Hospital, Geneva, Switzerlandb Service of Transplantation, Geneva University Hospital, Geneva, Switzerlandc Service of Nephrology and Histocompatibility laboratory, Zurich University Hospital, Switzerlandd Transplant Immunology Unit and National Reference Laboratory for Histocompatibility (LNRH), Division of Immunology, Allergy and Laboratory Medicine, Geneva, Switzerlande Department of Nephrology, Prince of Wales Hospital and Clincal School, University of New South Wales, Randwick, Sydney, Australiaf Organ and Tissue Authority, Australia

Summary

Growing incidence of end-stage renal disease, shortage of kidneys from deceased donors and a better outcome for recipients of kidneys from living donor have led many centres worldwide to favour living donor kidney transplantation programmes. Although criteria for living donation have greatly evolved in recent years with acceptance of related and unrelated donors, an immunological incompatibility, either due to ABO incompatibility and/or to positive cross-match, between a living donor and the intended recipient, could impede up to 40% of such procedures. To avoid refusal of willing and healthy living donors, a number of strategies have emerged to overcome immunological incompatibilities. Kidney paired donation is the safest way for such patients to undergo kidney transplantation. Implemented with success in many countries either as national or multiple regional independent programmes, it could include simple exchanges between any number of incompatible pairs, incorporate compatible pairs and non-directed donors (NDDs) to start a chain of compatible transplantations, lead to acceptance of ABO-incompatible matching, and integrate desensitising protocols. Incorporating all variations of kidney paired donation, the Australian programme has been able to facilitate kidney transplantation in 49% of registered incompatible pairs. This review is a plea for implementing a national kidney paired donation programme in Switzerland.

Friday, April 17, 2015

Inside Higher Ed has the story, on the clash when a transaction that some regard as repugnant is regarded as protected by others: Momentum for Campus Carry

"At least 11 states are considering whether to allow concealed weapons on college campuses this year, the latest chapter in a now seemingly annual legislative debate between gun control advocates and gun rights supporters.

"Bills have been introduced, at least once, in almost half of the 50 states in the past few years. Despite slow success thus far -- just seven states have adopted versions of campus carry laws -- gun rights advocates have their eyes on two very large prizes this year: Florida and Texas.

"Right now, the odds are starting to stack up in their favor. The Texas bill has passed the Senate and is on its way to House. The version in Florida has passed through two Senate committees and is headed to the Judiciary Committee.
...
"Yet for all its familiarity, the idea of guns on campus is relatively novel. Campus carry was largely a nonissue a decade ago, when the University of Utah went to court to defend its autonomy and the related right to stay gun-free. A few years later, Oregon, Mississippi and Wisconsin began explicitly allowing guns on campus.

"In all, seven states have laws that allow concealed guns on campus, though the details vary on who can carry where. Twenty states still ban carrying a concealed weapon on a college campus, and 23 states leave the decision up to individual colleges."

Thursday, April 16, 2015

I've written a lot about how marketplaces have to help markets become thick, deal with the congestion that can accompany thick markets, and make the market safe to participate in. I just got a nice email from Uber illustrating how they are thinking about that third point, on the rider side of the market.

BACKGROUND CHECKS

Drivers pass
federal, multi-state, and county background checks before driving.

Wednesday, April 15, 2015

"It didn’t take long after D.C. started doling out parking spaces to the city’s food trucks that the D.C., Maryland and Virginia Food Truck Association hit on one unfailing principal of economics: Where one market pops up, a secondary market will surely follow.

Food truckers, after getting their assigned spaces in the city's mobile roadway vending zones each month, were frantically hitting up the association’s message board with requests to trade days. It made for way too many emails, and not a lot of successful trades.

So the DMVFTA decided to find a better way. Now, a few months later, the association is about to launch its very own digital trading platform on its website.

...

"Hoffman had a group of masters students who needed a final project. With her guidance, those students developed a proof-of-concept program that took into account the truckers’ preferences for trades and automatically assigned new slots. In the end, the program spits out a new schedule for assigned spots that can be submitted to the D.C. Department of Consumer and Regulatory Affairs, so they are able to enforce the assignments."